Acute ischemic stroke and mechanical thrombectomy
Stem
A 72-year-old woman, 64 kg, with atrial fibrillation not taking anticoagulants, developed left hemiplegia and right gaze deviation two hours ago. NIHSS is 18. CT shows no hemorrhage and CT angiography a right M1 occlusion; she has received tenecteplase 16 mg. She is restless but answers questions and handles her secretions. Blood pressure 192/98, heart rate 96 irregular, SpO2 95%. The interventional team wants her on the table in 15 minutes.
Question
How will you manage anesthesia for her thrombectomy?
Ideal answer
HeadlineTime is brain: procedural sedation unless her airway or agitation forbids it, and I guard her blood pressure, because hypotension before recanalization kills penumbra.
- Bring her pressure to 180/105 or less, gently, because she has had thrombolysis; labetalol or nicardipine in small steps.1
- Light sedation and groin local, no delay for lines, because sedation and general anesthesia give the same functional outcome in nine trials.2
- Convert early and deliberately, not in a crisis: vomiting, agitation or a failing airway; vasopressor running before induction.
- Systolic 140–180 until the vessel is open, because every 10 mmHg fall in mean pressure worsens outcome.3
- After reperfusion, no intensive target below 140, which is harmful in the first 72 hours.4
Watch for: sudden hypertension with bradycardia, or contrast outside the vessel: perforation.
Breaking down the answer
- Why sedation is not a reflex choice either — general anesthesia brings a still patient and more successful reperfusion (OR 1.86, number needed to treat 11), with equal function.2 Changes if: low GCS, bulbar or posterior-circulation stroke, vomiting, uncontrolled agitation.
- Why observational data blamed general anesthesia — intubation delay, induction hypotension and volatile vasodilation; trials that treated hypotension promptly erased the difference.3
- Intraprocedural pressure — SNACC advised systolic 140–180.3 Mean pressure falls over 40% from baseline predicted poor outcome; under sedation, each 10 mmHg below a mean of 100 raised the odds of poor outcome 28%.3
- Thrombolysis thresholds — the bolus waits for under 185/110, and the post-lysis ceiling holds for 24 hours; the ESO applies the same ceilings to thrombectomy without lysis, with moderate certainty.1
- After recanalization — class 3 harm for a target below 140 for 72 hours in anterior circulation occlusion reperfused to mTICI 2b–3;4 the ESO says the same for the first 24 hours.1
- Who qualifies — ICA or M1 occlusion, NIHSS 6 or more: within 6 hours if prestroke mRS 0–1; at 6–24 hours with DAWN or DEFUSE-3 imaging; large cores (ASPECTS 3–5 at 6–24 hours, 0–2 within 6 hours) if under 80.5
Follow-up question
After the second pass she becomes unresponsive, heart rate falls to 48 and blood pressure rises to 214/112. The run shows contrast pooling outside a right M2 branch. What do you do?
Follow-up answer
HeadlineVessel perforation with intracranial hemorrhage; I say so to the room, secure her airway and drop her pressure.
Rapid sequence intubation, since she has lost airway protection. I lower systolic pressure quickly and reverse any heparin with protamine.6 Tenecteplase was a single bolus, so I treat post-lytic hemorrhage: cryoprecipitate 10 units toward fibrinogen above 150 mg/dL,7 and an antifibrinolytic, tranexamic acid 10 mg/kg IV.8 The interventionist tamponades with a balloon or sacrifices the branch. Perforation occurs in 0.6–4.9% of procedures, and mortality was 13% with reperfusion versus 56% without, so completing reperfusion matters.6 Then CT and neurosurgery for raised intracranial pressure.
Pitfalls that cost points
- Hyperventilating to protect the brain: hypocapnia constricts the collaterals feeding her penumbra.
- Delaying groin puncture for an arterial line or a planned general anesthetic in a patient who can lie still.
Rapid-fire
Q: What is the tenecteplase dose? A: 0.25 mg/kg, maximum 25 mg, as one bolus; 0.4 mg/kg is not recommended.5
Q: And alteplase? A: 0.9 mg/kg.5
Q: Should hyperglycemia be driven to 80–130 mg/dL with insulin? A: No; the 2026 guideline gives it a no-benefit recommendation.5
Q: How often does vessel perforation complicate thrombectomy? A: 0.6–4.9% in large trials; 2.3% in one center, falling over time.6
Q: Does sedation versus general anesthesia change three-month independence? A: No: OR 1.23, crossing 1, across eight trials.2
Numbers to know
| Item | Value |
|---|---|
| Before thrombolysis | <185/110 mmHg1 |
| During and 24 h after thrombolysis | <180/105 mmHg1 |
| During thrombectomy (SNACC) | Systolic 140–180 mmHg3 |
| After reperfusion | No target <140 mmHg for 72 h4 |
| Tenecteplase | 0.25 mg/kg, max 25 mg5 |
| Perforation mortality | 13% reperfused vs 56% not6 |
Links
- Anesthesia in MRI and remote locations, Subarachnoid hemorrhage and aneurysm clipping, Raised intracranial pressure: evaluation and reduction, Carotid endarterectomy, Atrial fibrillation: new onset and chronic
- AHA/ASA Guideline for the Early Management of Acute Ischemic Stroke (2026); SNACC consensus on anesthesia for endovascular stroke treatment (2014)
Sources
- 1.ESO guideline on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage (2025 update) · European Stroke Organisation (Guideline Central summary), 2025 · guidelinecentral.com
- 2.General anesthesia or conscious sedation for thrombectomy in stroke patients: an updated systematic review and meta-analysis · Canadian Journal of Anesthesia, 2023 · link.springer.comGeraldini F, et al. Can J Anesth 2023;70:1167-81. 9 RCTs, 1,342 patients.
- 3.Blood Pressure Management Before, During, and After Endovascular Thrombectomy for Acute Ischemic Stroke · Seminars in Neurology, 2021 · pmc.ncbi.nlm.nih.govde Havenon A, et al. Semin Neurol 2021;41:46-53; reports the 2014 SNACC target SBP 140-180 during EVT.
- 4.2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke · AHA/ASA, 2026 · doi.orgPrabhakaran S, et al. Stroke 2026; doi:10.1161/STR.0000000000000513; published online January 26, 2026.
- 5.2026 Guideline Update: Early Management of Acute Ischemic Stroke · emDocs, 2026 · emdocs.netQuotes thrombolytic dosing, EVT windows, large-core and glucose recommendations of the 2026 AHA/ASA guideline.
- 6.Successful Reperfusion is Associated with Favorable Functional Outcome despite Vessel Perforation during Thrombectomy · American Journal of Neuroradiology, 2022 · ajnr.orgDucroux C, et al. AJNR 2022;43:1633-38.
- 7.Protocol: neurological worsening after alteplase (symptomatic ICH management) · UTHealth Houston Institute for Stroke and Cerebrovascular Disease · uth.eduCryoprecipitate 10 units, fibrinogen >150 mg/dL; derived from the AHA/ASA scientific statement on hemorrhagic transformation after IV alteplase (Yaghi S, et al. Stroke 2017;48:e343-61).
- 8.Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke · Frontiers in Neurology (Charbonnier, Bonnet, Biondi, Moulin), 2020 · europepmc.orgTable 4 reproduces the AHA/ASA (Yaghi 2017) reversal suggestions for sICH within 36 h of alteplase: cryoprecipitate 10 U toward fibrinogen >=150 mg/dL; tranexamic acid 10 mg/kg 3-4 times daily or aminocaproic acid 4 g then 1 g/h, especially if blood products are unavailable or declined.
Facts on this page were checked against these sources on Oct 22, 2026. Guidelines change; confirm doses against current institutional protocols.